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Chiropractic Journal of Australia : CJA September 2012
Chiropractic Journal of Australia Volume 42 Number 3 September 2012 95 The diagnosis of FAI should be made through synthesis of the patient history, physical examination, and radiographic fndings. The diagnosis should not rely on radiographic fndings alone. It should be noted that plain flm radiographs are often reported as normal. An inability to recognise the morphological abnormalities, or a lack of access to imaging, does not surpass an indicative patient history and physical examination fndings, which includes a positive impingement test.19 Palmer24 stated, “Imaging abnormalities alone are not suffcient. Clinical symptoms and signs are essential to the diagnosis of FAI.” The abnormal loading through the femoral head-neck junction and the acetabular rim predispose patients to functional restrictions, articular cartilage and labral damage, and subsequent DJD.15 Therefore, it is crucial that a timely diagnosis of FAI can be made in order to improve management of this condition, and provide an opportunity for joint preservation.15 Conservative Treatment Within the literature, a number of publications have suggested FAI warrants an initial trial of conservative therapy.6,7,19,25-26 To the knowledge of this author, there is only one study27 documented within the literature which indicated positive early results in the conservative management of patients with mild FAI, so long as the patients can modify activities of daily living to adapt to their abnormal hip morphology. Emara et al27 utilised four stages of conservative treatment in their study: (1) avoidance of excessive physical activity and the use of non-steroidal anti-infammatory drugs (NSAIDs) for 2-4 weeks; (2) stretching exercises for 2-3 weeks to improve hip external rotation and abduction, in both fexion and extension; (3) determine the safe range of motion (between maximal internal and external rotation) to avoid FAI, and instruct patients to adapt their safe range of motion into activities of daily living; and (4) modifying activities of daily living predisposing to FAI (e.g. hip internal rotation associated with fexion and adduction). At the 24-month follow-up, the conservative treatment did not improve hip range of motion, and 18% of patients had recurrent hip pain and discomfort.27 Conservative management of FAI is a diffcult clinical challenge as various therapeutic methods may be effective for relieving acute pain in the short-term, but some treatment approaches may, in fact, exacerbate the condition.7 The goal of any conservative treatment approach is to decrease the mechanical contact (impingement) between the femoral head-neck junction and the acetabular rim.27 It has been stated that NSAIDs, relative rest, activity modifcation or avoidance, hip range of motion therapy, treatment to improve hip fexor tightness, stretching to improve hip external rotation and abduction, as well as core and hip muscle strengthening should be utilized as part of the initial trial of conservative treatment .6,7, 10, 19, 26, 27 Conversely, it has been suggested that stretching or other techniques to improve passive hip range of motion (e.g. manipulation/mobilization) may exacerbate the symptoms.7,12,19,28 Given the mechanical nature of FAI, conservative treatment will not eliminate the underlying morphological abnormalities, and attempts to return to previous athletic activities (or activities of daily living which involve recurrent or prolonged hip fexion or de-fexion) will simply aggravate the condition and cause symptoms to recur.7,19 Huang and Parvizi14 stated, “Nonoperative treatment is generally unsuccessful for FAI.” More importantly, it has been declared that a delay in surgical correction of symptomatic FAI may lead to disease progression to the point where joint preservation is no longer indicated.8 Therefore, early surgical intervention is recommended to avert the pathological progression from impingement to end-stage DJD.27 Surgical Treatment The aim of surgical treatment for FAI is to improve the femoroacetabular clearance and eliminate the mechanical obstruction at the limits of the desired hip range of motion.13,18,28 The technical goals of joint preservation surgery (prior to advanced DJD) are to correct the joint pathomechanics, and to treat the associated acetabular articular cartilage and labral pathology.18 In cases of advanced DJD, prosthetic replacement surgery (total hip replacement, arthroplasty) is the orthopaedic treatment of choice,18 and is beyond the scope of this paper. Both open surgical techniques and arthroscopic treatment have been described in the operative management of FAI. Open surgical procedures involve openly dislocating the hip anteriorly, and any mechanical impingement of the femoral head-neck junction (Cam lesion) is directly visualised and excised, restoring the normal concave contour of the femoral head-neck junction.13 The pincer lesion can be addressed by acetabular rim-trimming.29 Reverse periacetubular osteotomy, rather than rim-trimming, may be appropriate if there is acetabular retroversion.29 Any labral or articular cartilage damage can be treated with debridement or repair as appropriate.13 Hip dislocation and open osteochondroplasty have been the mainstream FAI treatment in the past, but the favourable outcomes and reduced complications are increasingly observed in less invasive arthroscopic procedures.30 These emergent techniques are an attractive alternative to patients (particularly professional athletes), as arthroscopy avoids the trauma associated with open procedures, involves smaller incisions, spares the soft tissues, requires a shorter recovery time, and a complication rate of less than 1.5%.7,30 Arthroscopic management involves the patient being positioned in a supine or lateral decubitus position, with or without a specialised traction device. Two to three standard arthroscope portals anterior, anterolateral or posterolateral are used.13 Hip mobilisation during arthroscopy allows the orthopaedic surgeon to visualise the Cam-type and or pincer- type FAI, and also provides confrmation that the impingement has been eliminated by the surgical corrective procedures.3 Any Cam lesion visualised on arthroscopy can be corrected by femoroplasty to create a suffcient anterior concavity of the femoral head-neck junction.3 Pincer-lesions require resection of the acetabular rim responsible for the over-coverage.3 Acetabular articular cartilage and/or labral pathology can be treated with debridement (labral tear, acetabular chondral delamination); repair (torn labrum); and/or chondroplasty (acetabular lesions) as appropriate.13 Arthroscopy has been shown to signifcantly improve hip fexion from 111.2° at FEMOROACETABULAR IMPINGMENT JAROSZ
CJA June 2012
CJA December 2012